CERTIFICATION COMMISSION OF
NAMSS (CCN)
REQUEST FOR RETIREMENT
STATUS (Waiver) –
Calendar Year 2006
This request must accompany
your recertification application
Name:
Current
certification: (
) CPMSC (formerly CMSC)
( ) CPCS
Address:
Phone:
Fax:
Current
Certification Cycle Expiration:
October 31,
Number
of continuing education credits completed this cycle:
Date of
retirement:
I have
read the
Maintaining Certification
brochure, Section VII. Change In Status
of Certification.
I understand that, subsequent to the end of the recertification cycle
ending 12/31/2006, if I have been granted the retirement status, but then return
to work in the Medical Services Profession, reinstatement of my certification(s)
will require resubmitting an application with full fee, and re-taking and
passing the certification examination(s).
Signature
Date
Return this form and
attachments (recertification application, fees and list of continuing
education credits ) to:
Certification Commission of NAMSS
NAMSS Executive Office
2025 M
Attn:
Robert Hendrickson, Education and Certification Coordinator
P - 202-367-1196
F- 202-367-2196
FOR OFFICE USE ONLY
CCN
Decision date: ___________________
Date Applicant notified:__________________
Retirement status granted ______________
Request denied (reason):_______________